Your Money or Your Life: Debt Collection in American Medicine

The rise of an industry tasked with the collection of medical debts in the United States is a relatively recent development. Physicians and hospitals have long held themselves apart from profit maximization and have expressed a moral aversion to immiserating patients in the pursuit of unpaid debts. This is particularly true of nonprofit hospitals, which find their origins in almshouses, community associations and religious orders. In addition, while creditors have tremendous powers at their disposal in seeking to collect, including lawsuits, wage garnishment, and property liens, medical providers recoup relatively little even when they resort to such aggressive measures. Why, then, in the last forty years, have US nonprofit hospitals increasingly turned to third-party debt collection, debt sales, and lawsuits against patient debtors? Answering this question demands an investigation of shifts in health insurance, hospital finance, and the moral economy of care. It also requires an understanding of physicians’ progressive disengagement from debt collection. What was once an unavoidably personal negotiation has become an administrative and legal process divorced from clinical obligations. This talk draws on historical research and new data to explain how unremunerative practices causing financial harm to patients became standard practice. ABOUT THE AUTHOR Luke Messac is a physician and historian at Brigham and Women’s Hospital and Harvard Medical School. He received his BA from Harvard University, his MD and PhD from the University of Pennsylvania, and completed his residency training in emergency medicine at Rhode Island Hospital. Dr. Messac’s early research was on the history and political economy of health care in Africa. His first book, No More to Spend (Oxford University Press, 2020) was a history of the practice of medicine under regimes of austerity in British colonial Africa. He has also published widely in medical and historical journals on a range of subjects including the development of national income accounting, the origins of trade regulations for medicinal opiates, and determinants of population-level mortality rates. His most recent work focuses on the rise of the medical debt collection industry in the United States. This is the subject of his book Your Money or Your Life (Oxford University Press, 2023). His has published in leading journals including the New England Journal of Medicine and Health Affairs and has testified before the United States Senate. He lives with his wife and two children in Pawtucket, Rhode Island.